Response to a Letter to the Editor on DSI Study

Recently, a letter to the editor was published in the Annals of Emergency Medicine. We were asked to respond in print, which we did. However, due to space limitations and the limitations of the Letter to the Editor System, we did not feel that the response was complete. Here is the complete response:

These opinions are those of the lead author and have been corroborated by the other authors of our DSI paper.

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Scott Weingart. Response to a Letter to the Editor on DSI Study. EMCrit Blog. Published on December 18, 2015. Accessed on January 21st 2019. Available at [http://emcrit.org/emcrit/response-to-a-letter-dsi/ ].

Financial Disclosures

Unless otherwise noted at the top of the post, the speaker(s) and related parties have no relevant financial disclosures.

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The authors of this letter seem to be missing the point of DSI and airway management in the critically ill, most notably with their title “danger in delaying definitive airway.” A more apt title might be: “Delayed Sequence Intubation: Avoiding premature intubation.” It is uncommon that intubation is an immediate necessity. Delaying intubation a few minutes to allow for supporting the patient’s physiology (e.g. start pressors for hypotension, preoxygenation) and completing preparations for intubation is generally a very smart move. Alternatively, rushing to intubate an agitated patient prematurely is a formula for disaster. I’ve had great results with DSI. The aspect that I appreciate most is that it allows us to take control the situation, slow down a bit, and think more clearly. Without DSI, these situations are often tense, the team is on edge, and people are not performing well. Once the patient is sedated, this allows us to relax, take a deep breath, run through the intubation checklist again, double-check the meds, communicate our plan, and make sure everything is ready. Sedation for pre-oxygenation obviously isn’t good for every patient. I have seen some cases where sedatives were administered (typically benzodiazepines) in efforts to alleviate a cooperative patient’s… Read more »

thanks buddy. I think most intensivists agree on this. I think it was George Kovacs who came up with the slogan Resuscitate, THEN intubate.

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3 years ago

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Craig Rosebrock MD

Intubations in the ED, ICU, OR, PACU and in the field are all potentially complicated by factors unique to the their setting.

I find that the cross analysis from those primarily in one arena can be biased with what I call the operators realm of perspective.

Scott you bring up a great point describing that most intensivist agree on Josh’s comments.

For me to go into the OR or come down to the ED and critique your practice (though welcomed from an academic perspective) may be misguided since I do not work in that environment.

I find that the ICU and suspect that the ED are similar in that the semi urgent but not so urgent that I cant wait airways are the worst. When the pt codes it a chip shot to just go but when they are still kinda fighting for life and you take away all their own drive, you better be ready for the post intubation aftermath. I think that anything that allows you to have more control is a great adjust to the more traditional dogmatic ways to do things.

One uncertainty about DSI remains for me: the pt who’s not starting hypoxic, but of course I still want to denitrogenate him, and he won’t let me due to his deliurium. For instance, a combative TBI pt satting 97% on RA, who needs intubation to allow safe prehospital transport, or to facilitate timely CT in the ED setting. I’m still DSI-ing this patient, because I want both the added safety of full denitrogenation and the calm preparatory environment Josh talks about above. Are you with me?

Bill–a good number of the DSI patients in the study and subsequently were solely for denitrogenation. I want to say a 1/3 of them but I don’t have the study in front of me right now. So totally agree.

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3 years ago

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Erik :)

Hi Scott. Interesting argument for DSI and subsequent response to the somewhat confusing letter to the editor. My take is that the writers are concerned that procedural sedation pre-intubation has the potential to derecruit, cause bradypnea, etc., resulting in actually worsened intubating conditions, and that this caveat might not be universally appreciated. Conceptually, I think DSI is a reasonable approach (although I continue to be baffled by this insistence on nasal cannula :)). My style is slightly different – depending on the situation if I am not able to effectively preoxygenate the patient while spontaneously ventilating I will induce and paralyze with a modified RSI, giving small gentle breaths while holding cricoid pressure. Obviously, this is not everyone’s cup of tea nor appropriate in all settings, but I’m comfortable with it.
On a more stylistic note, it may be because I listen to the podcast at 1.5x speed (I get through them faster this way), but this particular podcast seemed to me just a little bit petulant. I would have written the letter to the editor and then forgotten about it (or then brought up the subject with my friends over and over, which is more my style). Nice podcast.

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3 years ago

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Søren Rudolph

When using DSI you carefully titrate ketamine which vitually never will induced apnoea or bradypnea. Inducing paralysis and ventilating is actually what we want to avoid in these patients and though you may feel comfortable with this approach the evidence speaks otherwise.

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3 years ago

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Erik

Thanks for the response. I don’t think the data is that strong advocating any particular approach – ketamine can certainly depress respiratory function if used incorrectly; I personally don’t like the “classic” RSI because then I’m just sitting there looking at the sats going down, which is why I tend towards a ‘modified’ RSI. Induction with your choice of drug (where knowledge of the pharmacokinetics and patient physiology are arguably more important than the particular drug selected), paralysis, and careful ventilation certainly obviate the need for pt buy-in, and rapidly achieve a definitive airway. That said, different patients may call for different approaches and I’m sure there are many different ways to achieve the same goals. I just happen to like my way :).

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3 years ago

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leon

Hey Erik. I think your method is what the vast majority of clinicians – especially anesthesiologists – do when confronted with these patient scenarios. I think this method can work if you are a very fast and the patient isn’t really really hypoxic. In short, for the patients with a pulse ox of 92% on a non rebreather (who are intermittently pulling it off ‘cuz they are delirious), your method usually works just fine (as long as the tube goes right in the first shot with no problems. The issue becomes more dangerous for the really really hypoxic patients though – those saturating at 85% to begin with for example. I am an intensivist trained in airway by anesthesiologists and what you described is what most (but not all) of them did when they were outside of the OR when called for emergencies. So if the patient had a pulse ox to begin with of 85%, we would induce/paralyze them and try and get it up…. in reality most of the time the small amount of time between pushing the meds and the patient calming down and getting a mask seal was enough time for the saturation to drop more… Read more »

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2 years ago

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Erik

Sorry, I just saw this post today (5 months later!). Thanks for the thoughts – I’m always interested in maximizing patient safety – even tried the nasal cannula thing under the mask the other day – can’t say I’m a believer yet (and it screwed up my ETCO2) but I keep tinkering. Re the patient breathing with ketamine, a few things: ketamine has been around since the mid 60’s and it never really became ‘prime-time’, except for I suppose peds. People who have been around a while (and I mean like 40 years) seem to shy away from it – not sure why, secretions? Dysphoria? Anyway, because of that I don’t use it all that often – but then again, perhaps I should. The decision on when to take over a patient’s breathing is a tough one, especially if PPV is going to depress preload, or on an obese pt who will stop at nothing to de-recruit. I use a Mapleson-D (I think), which is way better than a BVM, even with a PEEP valve, because a) I have a PEEP valve, b) I can tell exactly what kind of tidal volume I’m getting with the set PEEP, and c)… Read more »

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2 years ago

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geoff martin

Hi Scott,
Thanks for DSI.
The essence of resus is delivering oxygen to the patient safely.
DSI, is a step in delivering effective oxygenation.If DSI allows an obtunded patient to come back from the brink as you have described and look after their own airway – that is the ultimate airway.
A definitive airway is just a method of delivering O2 and RSI is not the object of the exercise anymore than DSI.
Great job

I am a state EMS medical director and we have noticed a trend for pre RSI hypotension and or hypoxia to set up patients for a post RSI arrest. We are educating many pre hospital providers/ medical directors to try and maximize pre RSI resuscitation. We also really like the idea of using ketamine and then either bagging the patient up prior to paralytics if they are hypoxic as trying to get the BP up. We just got abstracts at SAEM accepted looking at vital signs prior to RSI how they can help predict who is more at risk for post RSI cardiac arrest.

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2 years ago

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Sean Hall

I am a Paramedic and an RN in rural Maine where we have been using these techniques discribed for in my opinion for years. Dr Peter Goth has validated these through the techniques of airway management. Airway management more specifically definitive management is not a rushed event but a very methodical decisive process there is nothing rapid about it, as it usually results in failure, where failure is not an option. The fact is this we in rural ER’s and in the pre hospital setting do not have resources to pull should things not go right, hence DSI prevents failure, reflected in Maine’s high success rate pre hospital and in the small rural hospitals their success in early agressive definitive management of unstable airways successfully.
Sean Hall CCT Paramedic RN